Session #75, February 12, 2019
Teddy Shah, FHIMSS, Vice President, Optum Advisory Services
Philip Strong, MD, Chief Medical Information Officer, Santa Clara Valley Medical Center
New Approaches for Bending the Cost Curve
through Whole Person Care
• Philip Strong, MD, Chief Medical Information Officer, Santa Clara Valley Medical
Center
• Teddy Shah, FHIMSS, Vice President, Optum Advisory Services
• Salary: None
• Royalty: None
• Receipt of Intellectual Property Rights/Patent Holder: None
• Consulting Fees (e.g., advisory boards):
• Fees for Non-CME Services Received Directly from a Commercial Interest or their
Agents (e.g., speakers’ bureau): None
• Contracted Research: None
• Ownership Interest (stocks, stock options or other ownership interest excluding
diversified mutual funds): None
• Other: None
Conflict of Interest
2
Agenda
3
1
Background
2
Whole Person Care (WPC) and CMS Grant
3
Understanding the Population
4
Collaboration: Infrastructure Development
5
WPC Approach and Design
6
Results and Key Takeaways
• Discuss distinction between Value Based Care and Whole Person Care
• Describe successes and lessons learned of a large safety net hospital in
implementing Whole Person Care principles
• Apply lessons learned by this large safety net organization to their own
organizations’ unique situations
Learning Objectives
4
Agenda
1
Background
2
Whole Person Care (WPC) and CMS Grant
3
Understanding the Population
4
Collaboration: Infrastructure Development
5
WPC Approach and Design
6
Results and Key Takeaways
5
County of Santa Clara Health System
• County has 1.8 million residents and is part of the San José-
Oakland-San Francisco combined statistical area
• The 2
nd
largest public hospital system in CALIFORNIA
• Integrated system since 1977
• $2.1 billion safety net serving mainly MEDICAID patients
The Santa Clara Valley Medical System is a
with 574 beds
LEVEL 1 TRAUMA CENTER
(trauma, burn and spinal cord and brain injury
rehabilitation centers)
6,680
employed staff
6
A safety net system in Silicon Valley
• San José 2012 median income:
$76,000 (U.S. $51,000)
• 45% of Santa Clara County
households make more than $100,000
• 33.5% of households in Santa Clara
County earn below the living wage
• Fourth largest number of homeless
individuals of all U.S. metro areas
(6,681)
• San José 2012 median income:
$76,000 (U.S. $51,000)
• 45% of Santa Clara County
households make more than $100,000
• 33.5% of households in Santa Clara
County earn below the living wage
• Fourth largest number of homeless
individuals of all U.S. metro areas
(6,681)
7
• Mature EHR Implementation from a single vendor
– Achieved HIMSS Stage 7 Certification (inpatient and outpatient)
– Enterprise Data Warehouse (EDW) built around same vendor
• Custody (county jail) went live on same platform (as inpatient facility)
– All custody patients are registered in the EHR
– All custody patients are screened on intake: Substance Use Disorder
(SUD), Serious Mental Illness (SMI)
• Progressive Valley Homeless Healthcare Program (VHHP)
– Serves a large base of patients adversely affected by social determinants
of health (SDOH)
• Willing to bring Behavioral Health Services (BHS)/Substance Use
Treatment System (SUTS) providers on a common platform county-wide
Santa Clara health system advantages
8
Agenda
1
Background
2
Whole Person Care (WPC) and CMS Grant
3
Understanding the Population
4
Collaboration: Infrastructure Development
5
WPC Approach and Design
6
Results and Key Takeaways
9
Key drivers
Source: “The Relative Contribution of Multiple
Determinants to Health Outcomes”, Laura McGovern
et al., Health Affairs, Health Policy Brief, 2014
Publication: Different Perspectives for
assigning weights to determinants of health.
80% of factors
that impact health
are non-clinical
POLICIES &
PROGRAMS
Clinical care
(20%)
Physical
environment (10%)
Health behaviors
(30%)
Social and economic
factors (40%)
HEALTH
FACTORS
Tobacco Use
Diet & Exercise
Alcohol & Drug Abuse
Sexual Activity
Access to Care
Quality of Care
Education
Employment
Income
Community Safety
Family & Social Support
Air & Water Quality
Housing and Transit
HEALTH
OUT COMES
Length of Life: 50%
Quality of Life: 50%
County health rankings model ©2014 UWPHI
10
Value Based vs. Whole Person Care
• “Value Based Care (VBC) is a healthcare delivery model in which providers,
including hospitals and physicians, are paid based on patient health
outcomes.”
1
• “The overarching goal of Whole Person Care (WPC) is the coordination of
medical, behavioral health and social services (particularly for those with
complex needs) to improve beneficiary health and wellbeing through more
efficient and effective use of resources.”
2
1
NEJM Catalyst, Jan 1 2017: https://catalyst.nejm.org/what-is-value-based-healthcare/
2
Ca.gov: https://www.dhcs.ca.gov/services/pages/wholepersoncarepilots.aspx
Whither waiver for California?
Medi-Cal 2020 key waiver programs:
• PRIME - Public Hospital Redesign and Incentives in Medi-Cal
58 Metrics; mostly P4P
• GPP – Global Payment Program
Get “points” (that translate into $$)
• WPC – Whole Person Care
Enroll in programs but get paid for services
Whole Person Care (WPC) goals
Required partners:
• Medi-Cal managed care
health plan
• Health services agency
• Specialty mental health agency
• Public agency
• Community partners
Partners work together to:
• Identify target population
(common high utilizers)
• Share data
• Coordinate care in real time
• Evaluate individual and
population progress
Overarching goals
• Coordination of health, behavioral
health, and social services
• Comprehensive coordinated care
for the beneficiary resulting in better
health outcomes
• Infrastructure that will ensure local
collaboration over the long term
• Reduce inappropriate emergency
department and inpatient utilization
$1.5 billion total federal funds
over five (5) years
13
Criteria
# of pilots
High utilizers with repeated incidents of avoidable ED use, hospital
admissions or nursing facility placement
15
High utilizers with two or more chronic conditions
3
Individuals with mental health and/or substance use disorder conditions
8
Individuals who are homeless/at
-risk for homelessness 14
Individuals recently released from institutions
(i.e.,
hospital, county jail, IMD, skilled nursing facility)
7
Statewide target population
14
Statewide services and interventions
4
4
4
4
6
9
11
15
17
Mobile services
Post-incaceration services
Respite services
Sobering centers
Mental health
Wellness and eduation
Housing services
Care management
Flexible Housing Pool
15
Note: Numbers represent the distinct programs available in the state of CA
Agenda
1
Background
2
Whole Person Care (WPC) and CMS Grant
3
Understanding the Population
4
Collaboration: Infrastructure Development
5
WPC Approach and Design
6
Results and Key Takeaways
16
• Engages in multiple systems
(medical, mental health,
substance abuse) = fractured care
• Relies on urgent/emergent
services ― ED, Emergency
Psychiatric Services (EPS),
inpatient, urgent care, mobile
crisis, ambulance
• Is less visible because not usually
highest user of a single system
• Suffers from multiple disorders
(serious medical, psych, addiction)
• History of poor medication adherence
• Bears a higher burden of chronic
diseases and premature death rates
• Is often homeless (shelter-seeking) and
difficult to engage
High Users of Multiple Systems (HUMS)
17
Point system for HUMS
The point system evaluates the number of clinical events for each patient
and assigns a number of points for each event
18
EVENT TYPE (NUMBER OF POINTS)
EXAMPLE POINTS
1. Inpatient stay (1 point/day)
5 day stay in defined timeframe 5
2. ED admission (3 points/event)
1 ED event in defined timeframe 3
3. Emergency Psych Admission [EPS] (3 points/event)
1 EPS event in defined timeframe 3
4. Acute psych care facility (BAP) (1 point/day)
2 day stay at BAP in a defined timeframe
2
5. Urgent/express care (1 point per event)
5 urgent care events in a defined
timeframe
5
16
High utilizer pyramid for tiered service
coordination
CCTP: the top 50
HUMS: the top 9,000+
Next Generation WPC
eligible: the top
20,000+
• CCTP: Care Coordination in
Transitions Program
• HUMS: High-Utilizers of Multiple
Systems: WPC Phase 1
• Next Generation WPC eligible: WPC
Phase 2 using community workers
• The big question: How to apply the
lessons learned with very-high
utilizers down the pyramid
effectively to balance quality/cost?
CCTP: Proof of concept for lowering costs
CCTP Start
Know your HUMS: Listening methods
Qualitative (listening sessions)
45 listening sessions (39 SCC, 6 external), 99 participants
Inclusion criteria: programs or clinics serving HUMS or other patients with
complex needs
Program identification: existing inventory, referral
Literature review
Peer-reviewed and gray literature on care/case management programs and
high utilization
Quantitative
Population: Medi-Cal patients ages 18−64, no dementia,
HUMS score of 9+ in 2016
Data source: HealthLink and VHP claims
21
Agenda
1
Background
2
Whole Person Care (WPC) and CMS Grant
3
Understanding the Population
4
Collaboration: Infrastructure Development
5
WPC Approach and Design
6
Results and Key Takeaways
22
Infrastructure development: Data
aggregation in Epic EDW
Matched and merged
Matched for use cases
Wish List
Epic Data Warehouse (Caboodle)
Homeless
database
Custody
health data
Public Health
(PHIHS)
Medicaid
claims
Medical
data
Substance abuse
treatment data
EMS data
Inpatient
behavioral
health data
Non-SCVMC
inpatient acute
psych
23
• Completion of Data Use Agreements (DUA) - Tipping point to connect to the
Trust Exchange requiring considerable investment and lift by the Lead Entity (LE)
• Lack of Social Determinants of Health (SDOH) Integration - Infrastructure
investments industrywide focused more on clinical data than mental health,
social and behavioral data
• Silver bullet “products” don’t exist – Control by the LE over strategy related to
connectivity, aggregation of data and Business Intelligence (BI) allowed success
• Crawl, Walk, Run – Baseline not only your patient population, but also your
operations and evaluate how to engage the patient population meaningfully
• Streamline engagement with partners
Lessons learned
24
Agenda
1
Background
2
Whole Person Care (WPC) and CMS Grant
3
Understanding the Population
4
Collaboration: Infrastructure Development
5
WPC Approach and Design
6
Results and Key Takeaways
25
Drive consumer centricity through single point
of contact and deep patient insights, addressing
cultural and linguistic needs
Engaged clinical and administrative leadership
to align enterprise and drive delivery excellence
Use of multi-disciplinary, integrated care team
Engagement of extended care team, including
family, caregivers, and social support
DESIGN PRINCIPLES
Use of multi-channel reach, finding patients
where they are, across the continuum
Compliance
Provider
effectiveness
Quality
Patient
experience
Utilization
Total cost
of care
DESIRED OUTCOMES
Integrate and align with programs, services
and the care delivery network
Develop sustainable model that achieves
outcomes to allow program to exist beyond
funding
Data-driven and collaborate innovation and
performance management
Integrated Care Center to house integrated
team and enabling technology
Design principles for WPC conceptual model
A number of design principles were used to develop the Whole Person Care Conceptual Model
and are anchored in the state’s objectives and the system’s unique capabilities; in sum, these
principles drive the model toward the desired outcomes
26
Whole Person Care conceptual model
The Whole Person Care Model has a number of key components that, with effective
management and execution, will facilitate success of the program
27
Strategy & Leadership
Performance Management
Innovation Incubation
Social & Community
Programs
Care Delivery
Network
Behavioral
Health
Services
Care Management
Programs
ID & Strat
Reach &
Engage
Care
Plans
Integrated Care Center (ICC)
3
6
4
5
11
13
12
ID & Strat
Reach &
Activate
Manage
Care
Plans
7
8
9
Patient
Needs
1
10
Data & Technology
14
2
Patient needs
The medical, behavioral, and social needs of the population are diverse and complex;
understanding each patient’s unique needs is critical to effective engagement
28
Medical
• Frequent contact with care partner
• Prevention and wellness
• Coordination of services
• Timeliness of care
• Complexity of care
• Access to care
• Pharmacy
Behavioral
• Frequent contact with care partner
• Mental illness management
• Stigmatized by diagnoses
• Substance use treatment
• Inappropriate use of ER
• Access to care
• Disability care
• Pharmacy
• Family
• Homeless support
• Unstable housing
• Food assistance
• Transportation
• Lack of trust
• Medicaid churn
• Assistive devices
• Access to care
• Financial/legal
• Poverty and
disenfranchisement
• Coordination
of services
Social
Patient Needs
1
Population health care team
Build a strong, resourceful and well-coordinated interdisciplinary team acting as a
trusted patient advocate to focus on delivering integrated, multidimensional care and
services in traditional and non-traditional settings
29
Care Partner
Extended Support
Family, Caregiver, and
Social Support
• Family / Friends / Caregiver
• Community / Social
• Home Aides
• Translators
Case Manager
Single point of contact to lead complex care
management. Acts as the “quarterback” to
develop personalized care plans with all
care stakeholders.
Collaborates with Case Manager to help patient
navigate non-clinical care and support. Culturally
and regionally similar to patient. Primarily a
community-based resource.
Care Delivery
Multidisciplinary Integrated
Care Team. Coordinates with
Case Manager.
Behavioral
• Psychiatrist
• Psychologist
Medical
• PCP
• Specialist Provider
• Long-term Care
Patient
Complex Case
Management
Care CoordinationTransition Management Condition Management
ICC
2
Care management programs
The Population Health Care Team will integrate with core programs and services to
collaborate across service providers to effectively and efficiently administer the
patient’s care plan
30
Specialty Case Management
• Ryan White HIV/AIDS Program
• Positive Connections (HIV+)
• Community Living Connection (IOA)
• Nursing Home Transition and Diversion Program (IOA)
• Tuberculosis Case Management (Public Health)
Care Management
• VHP CCM / DM Programs
• PRIME
• VHHP (Inc. Backpack Program)
Behavioral Health
• BH Care Management
• Full Service Partnership
• CCTP (Care Coordination
and Transitions Program)
WellnessPatient-Centered Medical Home IntegrationUtilization Management
3
Care PartnerCase Manager
Single point of contact to lead complex
care management. Acts as the
“quarterback” to develop personalized care
plans with all care stakeholders.
Collaborates with Case Manager to help patient
navigate non-clinical care and support.
Culturally and regionally similar to patient.
Primarily a community-based resource.
Patient
Complex Case
Management
Care CoordinationTransition Management Condition Management
ICC
• Prior Authorization
• Referral Management
• Concurrent Review
• Discharge Planning
• Physician-Led Programs • Preventive
• Nutrition
• PRIME
Social and community programs
The Population Health Care Team will address social determinants
of health by collaborating with social and community programs
31
4
Housing
• Temporary Housing
• Permanent Housing
• Care Coordination Project (includes New Directions)
Food
• Emergency food assistance
• Food banks
• Healthy options
Transportation
• Non-emergent medical
• Non-medical
Other Social SupportAssisted /Supportive Living
Care PartnerCase Manager
Single point of contact to lead complex
care management. Acts as the
“quarterback” to develop personalized care
plans with all care stakeholders.
Collaborates with Case Manager to help patient
navigate non-clinical care and support.
Culturally and regionally similar to patient.
Primarily a community-based resource.
Patient
Complex Case
Management
Care CoordinationTransition Management Condition Management
ICC
• Medical Respite
• Board and Care Facilities
• Custodial Placement
• Legal and Financial Services
• Eligibility and Benefits
• Advocacy
Behavioral health services
The Population Health Care Team will integrate behavioral health services along with
clinical and social programs to address the significant needs of the target population
32
5
Medical / Behavioral Integration
• Integrated Care Delivery
Substance Use Services
• Mobile Treatment
• Substance Use Treatment
Services (SUTS)
• Vivitrol Program
• Sobering Station
Specialty Facilities
• Medical Respite
• Post-Acute Skilled Care /
Placement
• Nursing Home Placement
Care PartnerCase Manager
Single point of contact to lead complex
care management. Acts as the
“quarterback” to develop personalized care
plans with all care stakeholders.
Collaborates with Case Manager to help patient
navigate non-clinical care and support.
Culturally and regionally similar to patient.
Primarily a community-based resource.
Patient
Complex Case
Management
Care CoordinationTransition Management Condition Management
ICC
Custody ServicesPsychiatric Day Services
• Structured Daytime Activates • Integrated Services for Mentally Ill Parolees
• Offender Treatment Program
Care delivery network
There are a number of key elements that are required to enable and align
the care delivery network with WPC
33
Higher Priority Elements
Care delivery providers
BH providers
CHP clinics
Custody health
Other contractors
Valley Medical Center
ambulatory care
Valley Medical Center
Partner hospitals
Key elements
Network strategy
• Adequacy
• Growth
• Partnerships
• Value-based care
Contracting
• Incentives
• Terms
• Legal support
Measurement
and analytics
• Growth
• Provider performance
Enablement
• Community/engagement
• Integration
• Tools
Operations
• Credentials
• Data management
• Payment
6
Identification & stratification
Guided by the enterprise’s strategic goals, identify and stratify patients, using a
robust set of data and analytic methods, and incorporated into operational
workflows
34
Patient
needs
Data types Data enrichments Model inputs Rules prioritization Ops integration
Typical WPC/social
•
Behavioral
•
Claims
•
Clinical
•
CM/DM/UM
activity
•
Consumer
•
Demographics
•
HRA
•
Labs
•
Medical
•
Membership
•
Rx
•
Custody data
•
Eviction records
•
Homeless shelter
staff surveys
•
Homeless shelter
status
•
OSH data
•
Probation records
•
Social services
data
•
Gap weights
•
Gaps in care
•
Episode groupers
•
Predictive models
• Provider performance
measures
•
Service indicators/
flags
•
Conditions
•
Consumer
attributes
•
Gaps in care
− Clinical/HEDIS
− HCC/risk
− Network (OON/efficiency)
•
Risk
(cost/utilization)
•
Social
determinants
•
Social isolation
− Patient preferences
− Program participation
•
Customer goals
•
Feedback loop
from analytics
•
Modalities
•
Programs
hierarchy
•
Regulatory
•
Suppression
logic
•
Timing of value
•
Volume
Business
strategy/
goals
Provider
effectiveness
Quality
Patient
experience
Utilization
Total cost
of care
Compliance
Higher Priority Elements
7
Reach & activate
Employ multichannel capabilities to reach the most vulnerable individuals and engage
them in a standardized assessment process geared to develop a plan addressing their
goals across continuum of care
35
ED
“Meet the Patient Where They Are” across the Care Continuum
Activate
Urgent
Care
Inpatient LTAC/
Rehab/SNF
Home PCP Specialist Custody
Health
Homeless
Shelters
FQHCsCommunity
Partners
Integrated Care Center
Email
Virtual App
MailCall
Text Web
In Person
Multi-Channel Reach
Standard WPC
Assessments
(Needs & Risk
Assessment)
Patient Goals Multi-Disciplinary Care
Plan Collaboration
Via motivational interviewing and active listening
8
Manage care plans
The WPC future state model will develop one individualized care plan for each
life that holistically addresses the patient’s needs
36
ICC
Functional status & safety
Transitions of
care/ access
to care
Informed choices
Medication
management
Barrier to care/
impact to
treatment plan
Condition management
Prevention/ lifestyle
Patient
9
Integrated Care Center
The ICC will provide a common platform for the care team to facilitate
performance acceleration
37
10
Integrated Care PlatformIntegrated Care Platform
Performance Acceleration EnablementPerformance Acceleration Enablement
Population Health Care Team & ProgramsPopulation Health Care Team & Programs
Care Partner
Case Manager
Patient
Compliance
Provider
Effectiveness
Quality
Patient
Experience
Utilization
Total Cost
of Care
Compliance
Provider
Effectiveness
Quality
Patient
Experience
Utilization
Total Cost
of Care
Agenda
1
Background
2
Whole Person Care (WPC) and CMS Grant
3
Understanding the Population
4
Collaboration: Infrastructure Development
5
WPC Approach and Design
6
Results and Key Takeaways
38
Gardner Health Services (GHS)
• Study population
– 570 HUMS dual eligible patients assigned by Valley Health Plan (VHP)
– 87 with at least one ED visit at San Jose Regional past year
• Study period – 8 months
• Goal – Reduce ED visits
• Interventions – Engage, enroll and provide care coordination services
• Methodology – Iterative Plan-Do-Study-Act (PDSA) cycles
Roots Clinic
• 183 HUMS dual eligible patients assigned by VHP
WPC Phase 1: Two pilot projects
39
• 60 year old African-American woman walked into clinic Oct 2017
• Major depressive disorder on SSRI and TCA, 2+ chronic medical conditions, at
risk for homelessness
• Received 10 medical and behavioral health visits, 14 Face to Face meetings w
peer navigators, medical record review, case conference re care plan
• Re-diagnosed – Mania associated with depression, complicated by side
effects of chronic medication management
• Referrals – carotid US, neuro-psych testing, DME (cane), DDS, local CBOs for
housing counselling, legal aid, and emergency assistance
• Update – living situation stable, ongoing mental health services, no longer
visits ED
WPC case study – Roots Clinic
40
Gardner Health Services pilot
Emergency Visits
ED Visits
41
PDSA: Plan, Do, Study, Act
Challenges
Engaging the homeless population
Continued housing shortage in Santa Clara county
Immediate availability of mental health resources
PCP availability (appointments are scheduled months in advance)
Transportation resources needed
42
Current state of implementation
43
First two years of WPC focused largely on building
communication infrastructure especially between the hospital
and the FQHCs.
County is now beginning to test more innovative strategies to
enroll, engage, and treat patients (as we just outlined)
Electronic tools such as Epic Healthy Planet, risk scoring /
outreach will help better identify patients combined with
provider referral.
• Maintaining engagement with this
population is challenging
– Electronic case management is
not enough
– Many attempts to initially
engage patients are often
needed
– Texting, calls, letters may not
be enough – highest yield with
face-to-face enrollment, e.g.
with field-based staff
– Patients are often more
motivated during acute event
• There is no “one size fits all” approach
– At the “apex” of the pyramid, WPC
includes outpatient intensive care
– Need “step-down” and “step back-up”
services for high acuity HUMS
– Patient variation and complexity
probably requires weekly multi-
disciplinary case conference
Key takeaways
44
• Retrospective utilization scores (like HUMS) are just the beginning
– Accuracy of predictive models will likely vary significantly with
characteristics of your patient population
• Going forward, need to focus on distinct county advantages and distinct sub-
populations:
– Toward organizing health homes around county HUMS patients
– Based on county demographics: Diabetes
– And as a safety-net facility: Substance Use
– Custody (county jail) patients
• Need more temporary and permanent housing options
Et cetera
45
Contact information:
Teddy Shah, VP Advisory Services
teddy.shah@optum.com
Twitter: teddyzwings
LinkedIn: https://www.linkedin.com/in/teddyshah/
Philip Strong MD, Chief Information Medical Officer
Philip.Strong@hhs.sccgov.org
LinkedIn: https://www.linkedin.com/in/philip-strong-a79b971/
Thank you.
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